Community-Based ART Resulted in Excellent Retention and Can Leverage Community Empowerment in Rural Lesotho, A Mixed Method Study

Vandendyck, Martin; Motsamai, Mabaruti; Mubanga, Mwenya; Makhakhe, Sebakeng; Tunggal, Syanness; Jonckheree, Sylvie; Cutsem, Gilles Van; Shroufi, Amir; Decroo, Tom

doi:10.17140/hartoj-2-107

Cited by 25 publications

(37 citation statements)

References 11 publications

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“…Unlike past pilot programmes, facilities included in this evaluation had no staff dedicated to implementing CARGs and lacked the resources to routinely conduct community visits to CARG members . Yet, our results are consistent with findings from evaluations of pilot programmes , and these results bode well for other countries implementing the CAG/CARG model nationally.…”

Section: Discussionsupporting

confidence: 82%

“…Both clients and HCWs consistently self‐reported that CARGs improved adherence and reduced client loss to follow‐up. This is consistent with quantitative evaluations of pilot programmes, which found that clients in CAGs had lower rates of loss to follow‐up . Once sufficient person‐time in CARGs has accrued, quantitative analyses should be done to evaluate the impact of CARG membership on retention and viral suppression.…”

Section: Discussionsupporting

confidence: 69%

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The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

Bochner

Meacham

Mhungu³

et al. 2019

J Intern AIDS Soc

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Introduction Community ART Refill Groups (CARGs) are an antiretroviral therapy (ART) delivery model where clients voluntarily form into groups, and a group member visits the clinic to collect ART for all group members. In late 2016, Zimbabwe began a nationwide rollout of the CARG model. We conducted a qualitative evaluation to assess the perceived effects of this new national service delivery model. Methods In March‐June 2018, we visited ten clinics implementing the CARG model across five provinces of Zimbabwe and conducted a focus group discussion with healthcare workers and in‐depth interviews with three ART clients per clinic. Clinics had implemented the CARG model for approximately one year. All discussions were audio recorded, transcribed, and translated into English, and thematic coding was performed by two independent analysts. Results In focus groups, healthcare workers described that CARGs made ART distribution faster and facilitated client tracking in the community. They explained that their reduced workload allowed them to provide better care to those clients who did visit the clinic, and they felt that the CARG model should be sustained in the future. CARG members reported that by decreasing the frequency of clinic visits, CARGs saved them time and money, reducing previous barriers to collecting ART and improving adherence. CARG members also valued the emotional and informational support that they received from other members of their CARG, further improving adherence. Multiple healthcare workers did express concern that CARG members with diseases that begin with minor symptoms, such as tuberculosis, may not seek treatment at the clinic until the disease has progressed. Conclusions We found that healthcare workers and clients overwhelmingly perceive CARGs as beneficial. This evaluation demonstrates that the CARG model can be successfully implemented on a national scale. These early results suggest that CARGs may be able to simultaneously improve clinical outcomes and reduce the workload of healthcare workers distributing ART.

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Section: Discussionsupporting

confidence: 82%

Section: Discussionsupporting

confidence: 69%

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

Bochner

Meacham

Mhungu³

et al. 2019

J Intern AIDS Soc

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“…Implementation of patient‐centred ART care has been reported from several settings in sub‐Saharan Africa . Community ART Groups (CAGs) have been piloted in Malawi, Lesotho and Mozambique as a way to reduce patient time and costs spent travelling and queuing for ART refills . In Mozambique the CAG model retained 97.7% and 91.8% of patients at 12, and 48 months .…”

Section: Introductionmentioning

confidence: 99%

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

et al. 2018

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IntroductionA broad range of community‐centred care models for patients stable on anti‐retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community‐centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care.MethodsPatients on ART were enrolled into three community‐centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan–Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all‐cause attrition from care model and disengagement with ART.ResultsA total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12‐month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types.ConclusionsConcurrent implementation of three alternative community‐centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community‐centred care models adapted to their specific setting.

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“…Community embeddedness is one of the key arguments for the clubs’ sustainability and the cornerstone of DC models. The beneficial outcomes of peer support and active involvement in treatment were confirmed in other settings . Patients turn into experts in their treatment, from social support during group meetings and through sharing and combining their knowledge and experience .…”

Section: Discussionmentioning

confidence: 99%

“…Publications on ACs focus on the Cape Town area and are speculative as to how clubs would operate in lower socio‐economic settings. Given the evidence, ACs seem more eligible for urban or peri‐urban settings , whereas CAGs are successfully implemented in rural areas like in Mozambique, Malawi and Lesotho, with improved adherence to ART and reduced loss to follow‐up .…”

Section: Discussionmentioning

confidence: 99%

ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review

et al. 2019

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Introduction In 2007, the antiretroviral therapy (ART) adherence club (AC) model was introduced to South Africa to combat some of the health system barriers to ART delivery, such as staff constraints and increasing patient load causing clinic congestion. It aimed to absorb the growing number of stable patients on treatment, ensure quality of care and reduce the workload on healthcare workers. A pilot project of ACs showed improved outcomes for club members with increased retention in care, reduced loss to follow‐up and a reduction in viral rebound. In 2011, clubs were rolled out across the Cape Metro District with promising clinical outcomes. This review investigates factors that enable or jeopardize sustainability of the adherence club model in the Western Cape of South Africa. Methods A scoping literature review was carried out. Electronic databases, organizations involved in ACs and reference lists of relevant articles were searched. Findings were analysed using a sustainability framework of five key components: (1) Design and implementation processes, (2) Organizational capacity, (3) Community embeddedness, (4) Enabling environment and (5) Context. Results and Discussion The literature search identified 466 articles, of which six were included in the core review. Enablers of sustainability included the collaborative implementation process with collective learning sessions, the programme's flexibility, the high acceptability, patient participation and political support (to some extent). Jeopardizing factors revolved around financial constraints as non‐governmental organizations are the main supporters of ACs by providing staff and technical support. Conclusions The results showed convincing factors that enable sustainability of ACs in the long term and identified areas for future research. Community embeddedness of clubs with empowerment and participation of patients, is a strong enabler to the sustainability of the model. Further policies are recommended to regulate the role of lay healthcare workers, ensure the reliability of the drug supply and the funding of club activities.

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Community-Based ART Resulted in Excellent Retention and Can Leverage Community Empowerment in Rural Lesotho, A Mixed Method Study

Cited by 25 publications

References 11 publications

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review

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